As healthcare practitioners and institutions increase their adoption and use of electronic health records, the transition from paper-based to computerized provider documentation (CPD) is having dramatic effects on a range of healthcare and business processes, and not all of them positive.
In a study led by Dr. Peter Embi, a physician-scientist and vice-chair of The Ohio State University College of Medicine's Department of Biomedical Informatics, researchers from Ohio State College of Medicine analyzed feedback from 129 participant stakeholders, including 54 physicians and practitioners, 34 nurses and 37 administrators at five Department of Veterans Affairs medical facilities across the country.
"By studying the views of different types of professionals at multiple national sites, we were able to expand on previous research related to this new way of documenting clinical care," says Embi.
Among the findings, published online ahead of print in the Journal of American Medical Informatics Association, the researchers identified a range of impacts from CPD affecting critical clinical and administrative workflows and communication patterns.
"As CPD use increases and becomes the major way we capture clinical information in health care, it is affecting processes that impact clinical understanding, decision-making and communication," Embi adds.
The study's findings were grouped into five major themes of CPD impacts related to:
- Communication and coordination
- Control and limitations in expressivity
- Information availability and reasoning support
- Workflow alteration and disruption
- Trust and confidence concerns
While current CPD systems were felt to be, overall, better than paper, and were beneficial, they often fell short of meeting users' needs or led to problems, in part, because of what study authors attribute to an outdated 'paper chart' paradigm.
Researchers noted the same user types also shared common views, but they noted some important differences regarding the perceived purpose and effects of CPD between clinicians and administrators. For example, in general, the administrative group valued the completeness facilitated by templates, while the practitioner and nurse groups noted that, while templates could help facilitate documentation, restrictive templates generated less informative documentation than free text.
"The need for easy and rapid, yet structured and constrained, documentation often conflicts with the need for highly reliable and retrievable information to support clinical reasoning and workflows," Embi and colleagues say. They also noted a tension between efficient documentation and the need for accurate data collection to enable quality improvement and research, often limited by overuse of CPD features such as copy-and-paste.
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